Billing Procedures VA Veterans Choice Program and Patient-Centered - - PowerPoint PPT Presentation
Billing Procedures VA Veterans Choice Program and Patient-Centered Community Care Confidential and Proprietary Confidential and Proprietary Communication VCP and PC3 Billing Procedures - Webinar Questions? Just ask! Please use the Q&A pod
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Please use the Q&A pod section to submit your questions! We don’t want to miss them!
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Background, Need, Program Overview Appointment Scheduling & Authorization Overview Differences Between VA, TRICARE, Medicare, & Medicaid Provider Claims and Medical Documentation Provider Resources Provider Portal Demo
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The TriWest Provider Portal is your one-stop shop for information on filing claims and navigating the Department
www.triwest.com/provider
You can also find tools and additional education on TriWest’s Payer Space on Availity
www.availity.com
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VA needed to expand health care access for Veterans in communities across the nation VA awarded TriWest the Patient-Centered Community Care (PC3) Contract in 2013 In 2014, Congress introduced and President Obama signed into law the Veterans Access, Choice, and Accountability Act Section 101 established the Veterans Choice Program (VCP) and went live on Nov. 5, 2014
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Health Net Regions
Health Net Federal Services, Inc. HealthNetFederalServices.com
TriWest Regions 3,5A, 5B, and 6
TriWest Healthcare Alliance
1-855-PCCCVET (855)-722-2838
www.triwest.com/provider
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The Veterans Choice Program (VCP) is part of VA’s Patient-Centered Community Care (PC3) Program VCP provides eligible Veterans with community access to primary care, inpatient and outpatient specialty services, and behavioral health care VCP is Veteran-driven All Veterans enrolled for care with VA as of Aug. 1, 2014 received a Choice Card
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Veterans’ eligibility to use their Choice Card in the private sector is determined by VA using the following criteria:
The closest VA Medical Center (VAMC) or Community- Based Outpatient Clinic (CBOC) with a full-time Primary Care Manager is greater than 40 miles from their home-Choice 40 mile or distance eligible They are, or will be, on a wait list of 30 days or more with a VAMC-Choice 30 day Services are not available at VAMC-Choice First The closest VA medical facility is not easily accessible from their home or there are significant geographic barriers
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When a Veteran needs to make an appointment, refer them to the number on the back of their Choice Card If you would like to schedule an appointment on their behalf, call TriWest to make the appointment: 1-866-606- 8198
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VA sends referral to TriWest (PC3, Choice First,
day) PSR locates VCP/PC3 provider PSR makes appointment
Veteran TriWest sends authorization to provider via fax Veteran calls TriWest to confirm VCP eligibility- Choice 40 mile
OR
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To avoid claims denials, all care requires an authorization from TriWest before services are rendered If a provider renders care without an authorization, he/she risks losing reimbursement Providers CANNOT balance-bill Veterans or charge for no- shows
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Routine labs and X-rays are included in TriWest authorizations For surgeries, anesthesiology services are also included in authorizations Include the authorization number with your order form for the labs, X-rays, or anesthesiologist Instruct the ancillary provider to include the authorization number on its claim when billing TriWest
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If you’re an ancillary provider and receive an order to treat a Veteran using his/her VA community benefits:
The order should include the authorization number If you’re not sure, call the prescribing provider’s office to confirm, and obtain an authorization number Bill TriWest for your services and include the authorization number on your claim
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VA – Veterans (Prior Military Service)
Covers those who once served in the military, but have now either separated or retired and are no longer active duty Benefits fall under the Department of Veterans Affairs (VA) Different than the Department of Defense TriWest only administers VA community programs
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TRICARE – Active Duty Service Members, National Guard/Reserve, and Their Families
Covers those who are currently serving in the U.S. Armed Forces, and their families Military retirees are also TRICARE-eligible (dual eligible) Program falls under the Department of Defense Receives funding through the defense budget Never bill TRICARE for a Veteran with a TriWest authorization
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Medicare – Civilians Ages 65 Years and Older or Disabled
Federal health care benefit available to U.S. civilians ages 65 and older Veterans may have both Medicare and VA benefits If you have an authorization from TriWest, always bill TriWest – not Medicare
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Medicaid – Medical Insurance for Financially Disadvantaged
Federal health care program for individuals living at or under the poverty line Threshold for eligibility varies from state to state Veterans may have Medicaid and VA benefits If you have an authorization from TriWest, always bill TriWest – not Medicaid
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TriWest does not contract with TRICARE, Medicare, or Medicaid Programs TriWest authorizations apply to Veterans only (not TRICARE) When you see a TriWest authorization, think “VA”
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Never bill TRICARE for services provided to a Veteran with a TriWest authorization Claims may be denied Always bill TriWest for Veterans with a TriWest authorization
Don’t bill Medicare Don’t bill Medicaid
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(1) Upload Medical Documentation to TriWest Provider Portal Register for a secure account on TriWest’s portal at www.TriWest.com/provider and upload medical documentation directly to TriWest’s system. If you are unable to access or upload via the Provider Portal, fax medical documentation to TriWest’s Behavioral Health team at 1-866-284-3736. Do not upload documentation with claims. WPS MVH cannot send your documentation to VA for review.
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(2) Submit Claims to WPS MVH
TriWest uses WPS MVH for all claims processing and can accept electronic claims through your clearinghouse/billing service or via
submit claims without an additional charge to the provider WPS requires providers to pre-enroll with WPS in addition to enrolling with their clearinghouse for electronic transactions To find clearinghouse Payer IDs, please visit: http://www.wpshealth.com/resources/provider- resources/edi/index.shtml or contact TriWest Provider Services at providerservices@triwest.com Mail paper claims to WPS MVH-VAPC3, PO Box 7926, Madison, WI 53707-7926. Paper claims must be on CMS compliant forms or they will be rejected
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Non-compliant claim forms cannot scan and will reject
CMS criteria on scale and color (OCR Red) are required
Minimize OCR errors
10-point Courier or Courier New 10 mono-space font with a 10-pitch setting Don’t mix fonts or use italics, script, percent signs, question marks, or parentheses Do not hand-write forms
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Electronic transactions can save an average of $23K per provider and hundreds of hours!* To submit claims electronically to WPS-MVH through a clearinghouse, Providers must pre-enroll for each type
EDI – submit claims electronically ERA – receive remittance advice electronically EFT – receive payment electronically
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*Based on an annual average of 6,200 claims submitted annually. Source: Milliman, Inc. “Electronic Transaction Savings Opportunities for Physician Practices,” Technology and Operations Solutions, Revised: Jan. 2006
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To get started with pre-enrollment, visit https://edi.wpsic.com/edir/home Be sure to have:
Your Trading Partner ID (the ID for your clearinghouse) Your practice information Which VA Region you practice in Your Tax Identification Number (TIN) Contact information for principle contact Business name Physical address (No P.O. Boxes) Your banking information, including routing numbers
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Let us help you!
Don’t know your region? Need to track down the WPS MVH Payer ID? Need to determine what your clearinghouse Trading Partner ID is?
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ProviderServices@triwest.com or 1-855-722-2838, Option #3, Option #4
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VA programs do not pay secondary Providers collect no copays, cost-shares, or deductibles from Veterans Providers are encouraged to submit claims within 30 days after services are rendered Claims must comply with the 180-day timely filing limit
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No payment will be made to providers for services rendered without a prior authorization from TriWest
Be sure to submit a Secondary Authorization Request and receive the approval for care PRIOR to providing services!
For more information, refer to the Provider Claims Quick Reference Guide located at www.triwest.com/provider and
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Claim status? Check on TriWest’s Provider Portal at www.triwest.com/provider Electronic Remittance Advice (ERA)? Ensure your clearinghouse offers ERAs and then enroll with WPS - https://edi.wpsic.com/edir/home
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Medical documentation submission is a requirement for both PC3 and VCP Medical documentation must be submitted to TriWest for all services to allow VA’s timely coordination of care for Veterans Do not submit medical documentation with claims, these will not be processed by WPS MVH Submit medical documents to TriWest as soon as possible after care, but within 30 days
Some specialties or critical findings have additional documentation requirements
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General outpatient care medical documentation/records:
Submit within 30 days via upload to the TriWest provider portal
Inpatient care medical documentation/records:
Submit at a minimum the discharge summary to TriWest within 30 days of discharge
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Urgent specialty care:
Submit to TriWest within two days Oral reports should be provided to VA Point of Contact within 48 hours when indicated on the authorization form
The authorization may request medical documentation be returned sooner based on clinical need
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Appeals on denied claims should be submitted within 90 days of the date of the Remittance Advice Send written appeals via mail sent to:
WPS MVH-VAPC3 PO Box 14491 Madison, WI 53708-0491
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Quick Reference Guide are at www.triwest.com/provider and TriWest’s Payer Space on Availity
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TriWest.com/provider and TriWest’s Payer Space on Availity – Your one-stop shop for information on filing claims and navigating VCP and PC3
Provider Handbook Reference Guides Webinar registration Newsletters Additional resources and links to important information
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Register for a secure account to:
Upload medical documentation Check authorization status (including SARs) Print authorization information Check claims status
Visit www.triwest.com/provider and click “Register for Secure Access”
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Availity = online, multi-payer site for you to work with TriWest and other health plans you accept Becoming TriWest’s new way to access the Provider Portal, online resources, and other tasks Register at www.availity.com
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TriWest PC3 Customer Service Line: 1-855-PCCCVET (1- 855-722-2838) TriWest Veterans Choice Program (VCP) Customer Service Line: 1-866-606-8198
Please access the Provider menu and enter the zip code for your practice if requested You can reach our team for Authorization questions, assistance with the Provider Portal, Claims questions and contracting or credentialing questions
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